Provider Demographics
NPI:1588774202
Name:QUILLEN, ERIC L (DDS)
Entity type:Individual
Prefix:DR
First Name:ERIC
Middle Name:L
Last Name:QUILLEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 FRANKFORT STREET
Mailing Address - Street 2:
Mailing Address - City:VERSAILLES
Mailing Address - State:KY
Mailing Address - Zip Code:40383
Mailing Address - Country:US
Mailing Address - Phone:859-879-5045
Mailing Address - Fax:859-879-5045
Practice Address - Street 1:156 FRANKFORT STREET
Practice Address - Street 2:
Practice Address - City:VERSAILLES
Practice Address - State:KY
Practice Address - Zip Code:40383
Practice Address - Country:US
Practice Address - Phone:859-879-5045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7449122300000X
WV2241122300000X
KY6531223X0400X
WV591223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60003100Medicaid
KY60003100Medicaid